| NPI | 1467889493 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2015-0017) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 5478) |
| Enumeration Date | 2013-10-04 |
| Last Update Date | 2015-05-29 |